Operative Technique: Karen Horvath, MD, FACS. SCOAP Retreat June 17, 2011

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1 Operative Technique: Total Mesorectal Excision Karen Horvath, MD, FACS University it of Washington, Seattle SCOAP Retreat June 17, 2011

2 No Disclosures

3 Purpose What is Total Mesorectal Excision (TME)? How is it different than non-tme techniques? Operative principles

4 What is TME?

5 Why should surgeons perform TME? Old surgical methods for rectal cancer leave tumor cells in the pelvis Tumor left in the mesorectum leads to local recurrence TME removes the intact mesorectum and does not leave tumor cells behind

6 The Problem: Local Recurrence of Rectal Cancer 85% cases occur within 3 years of surgery Local recurrence colon cancer = 7-10% Local recurrence rectal cancer = 25-50% 50% have disease limited to pelvis and no mets 70% die of disease within 3 years Severe pain with tumor invasion into the bony pelvis or local organs, tenesmus, bleeding, fungating foul-smelling masses, obstruction (Surg 1990;108:787, Br J Surg 1996;83:293)

7 Quality of Life: Bladder & Sexual Function Dyspareunia, failure to achieve orgasm, loss of vaginal lubrication, erectile dysfunction, retrograde ejaculation, impotence Difficulty in bladder emptying, urgency, incontinence, loss of sensation of fullness, recurrent urinary tract infections, neurogenic bladder TME: 0-10% Historical series: 10-50% Enker, Arch Surg 1992;127 Enker et al, JACS 1996;182:495

8 The Origin of TME : Mr. Richard J. Heald, MChir, FRCS Basingstoke, England Hypothesis: local l recurrence is a result of the surgeon leaving mesorectal residue in the pelvis Questioned traditional operative technique Developed the precise surgical dissection of the mesorectum known as TME

9 How is TME Different Than Non TME Techniques?

10 Old Proctectomy Techniques Partial direct vision (in upper pelvis only) Coned down excision of the mesorectum to 2cm beyond tumor Blunt dissection with violation of mesorectum

11

12 TME Principles Total excision of the mesorectum Direct vision Sharp dissection Avascular plane Ensuring an Intact fascial envelope containing the tumour (which avoids tumor spill) Nerve preservation for bladder and sexual fxn Sphincter preservation when possible

13 Rothenberger

14 Intersurgeon Variations: Minimizing These in WA State via SCOAP Variable Range (%) Morbidity and mortality year local recurrence year death from rectal CA APR rates (loss of sphincter) Holm et al, BJS, 1997

15 Required Instruments Headlight St. Mark s retractor (lighted) Staplers GIA, TA and EEA

16 Patient Position

17 Sharp Mesorectal Excision for Rectal Cancer Elements of Technique 1. Mobilize sigmoid and left colon 2. Identify ureters and sympathetic nerves 3. Mobilize splenic flexure 4. Divide colon and vascular pedicle 5. Separate sympathetic nerves 6. Aggressive anterior traction on mesorectum 7. Penetrate Waldeyer s to the bony pelvis

18 Left Pelvic Exposure

19 Right Pelvic Exposure

20 Splenic Flexure Mobilization

21 Bowel Division

22 IMA Clearance and Ligation of Vasculature

23 Sharp Mesorectal Excision for Rectal Cancer Elements of Pelvic Dissection Posterior dissection first Scissor spreading and cautery, after pentrating Waldeyer s fascia Along bony pelvis (parietal fascia) Through recto sacral fascia Up levators to level lof anus Anterior dissection second

24 Posterior Dissection Between Sympathetic Nerves at True Pelvis Entrance Waldeyer s fascia penetrated to bony pelvis (parietal fascia)

25 Posterior Dissection Through Rectosacral Fascia

26 Anterior Clearance in Women

27 Identification of Denonvillier s Fascia in Men

28 Sharp Mesorectal Excision for Rectal Cancer Lateral Clearance Clearance to levator fascia posterior and anterior allows dli delineation i of lateral stalks Main sidewall nerve trunk is S3 Most common site for damage is anterolateral Tumor location may not allow symmetrical clearance Laparoscopic vascular stapler, low energy cautery, bipolar cautery, clips all valuable avoid large clamp and suture ligation

29 Division of Right Stalks with Laparoscopic Vascular Stapler

30 ColoAnal Reconstruction After TME Double stapled end to end Colonic J Pouch Coloplasty l Rectal Pouch

31 Completion of TME Procedure Air insufflation per anus; saline in pelvis & hand clamp above Digital i rectal examination i +/ Proctoscopy +/ Drain Diversion Ileostomy Specimen assessment

32 Conclusions TME for rectal cancer: dramatically reduced local recurrence rates increased survival decreased incidence of bladder & sexual dysfunction sphincter preservation

33 Thank You!

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